Parental Involvement in Adolescents’ Reproductive Healthcare: History, Research, & Policy Options Claire Brindis, Dr.P.H.

Professor, Department of Pediatrics Department of Obstetrics, Gynecology & Reproductive Sciences Bixby Center for Reproductive Health Research & Policy Institute for Health Policy Studies University of California, San Francisco

September, 2006

In this presentation…

     What is the status of teen pregnancy, abortion, and childbearing in the United States? What relationship do healthcare professionals, policymakers, parents, and adolescents have regarding mandated parental involvement? What is the importance of parental involvement

and

confidentiality in the delivery of adolescent healthcare?

What is the current status of legislation mandating parental involvement in adolescents’ abortion decisions in the US?  Proposition 85 in California Do parental involvement laws have their intended impact?

Parental involvement requirements pertaining to abortion

Parental Notification Parental consent • Parent(s)/Legal Guardians must be notified, usually in writing, of a minors’ decision prior to provision of care • Mandatory waiting period often accompanies notification requirement • Minor retains decision-making capacity • Judicial bypass option for confidential treatment • Parent(s)/Legal Guardian(s) must give consent, usually written or in-person, prior to provision of care • Parent/Legal Guardian(s) may refuse to provide consent such that minor can not receive care •Minor retains ability to use judicial bypass • Mandatory waiting period often accompanies consent requirement

The frequency of adolescent pregnancies, births, and abortions



Adolescent pregnancy, birth, and abortion rates are currently at their lowest levels since the mid 1970’s.

Trends in Adolescent Birth Rates (Ages 15 to 17) California vs United States

50 45 40 35 30 25 20 15 10 California US 1985 1988 1992 1996

Year

1999 2002 2004 National Center for Health Statistics & The Alan Guttmacher Institute

The frequency of adolescent pregnancies, births, and abortions has substantially decreased Rates for 15-17 year old females, 1990-2000

120 100 80 60 40 20 0 80.3

53.5

102 60 Pregnancy rate 37.5

22.1

46 20.6

Birth rate (2004) 26.5

14.5

42 23 Abortion rate U.S. 1990 U.S. 2000 CA 1992 CA 2000 The Alan Guttmacher Institute, 2004; Sutton & Mathews, 2004

Declines in teen pregnancies, births, and abortions

Delayed sexual activity  Between 1998 & 2002, the proportion of adolescent women aged 15-17 who have ever had sex declined from 37% to 30%.

Increased use of contraceptives  Between 1995 & 2002, the proportion of adolescent women aged 15-17 that used contraceptives at most recent intercourse increased from 71% to 83%.

Increased availability of effective contraceptive methods   The proportion of sexually active teens who report having used the pill has increased from 52% to 61% between 1995 & 2002. Emergency contraception averts an estimated 4,000 unintended pregnancies to adolescents aged 17 and under each year.

Abma et al, 2004; Jones et al, 2002

Despite tremendous progress, adolescents continue to experience a high incidence of unintended pregnancy, birth, and abortion

California

5,290 15,110 18,914 39,320 39,920 84,770

United States

157,209 281,900

0 50,000 100,000 150,000 200,000 250,000 300,000 US teen pregnancy, birth and abortion rates continue to be among the highest in the developed world Miscarriages/stillbirths Abortions Births Pregnancies The Alan Guttmacher Institute, 2004

Confluence of Factors

Healthcare professionals Policymakers & advocates Parents Adolescents

Adolescents

The provision of confidential healthcare for adolescents has been promoted due to the recognition that some minors would not seek or would delay needed health care if they could not receive it confidentially.

Confidential healthcare & adolescents

   In a recent national survey, 1/3 of students who did not seek needed healthcare reported that one of their reasons was “not wanting to tell their parents” (Klein et al, 1999).

Assurances of confidentiality increase:



the number of adolescents willing to disclose sensitive health information (from 39% to 47%)



the commitment of adolescents to return for future healthcare visits (from 53% to 67%) (Ford et al, 1997).

Privacy concerns can also deter adolescents from communicating openly with providers about certain health concerns (Ford et al, 1997).

Confidential reproductive healthcare & adolescents

 The proportion of adolescents who report that they would forgo care for certain types of concerns (including contraceptives, STIs, substance use, and mental health) is higher than those that would forgo general health care if confidentiality was not ensured (Marks et al, 1983).

 Nearly ½ of young, sexually active females visiting a family planning in Wisconsin reported that they would stop using all sexual health services if parental notification were required, however the vast majority indicated that they would

not

stop having sex (Reddy et al, 2002).  One in 5 adolescents would stop using contraception or rely on an ineffective method (such as withdrawal) as one response to mandated parental notification for reproductive health care visits (Jones et al, 2005).

Parents

Parental communication, connectivity, and engagement is very important in adolescent decision making

Parent-child communication on issues of sex & sexuality

 Teens report that parents are the individuals that most influence their decisions about sex ( National Campaign to Prevent Teen Pregnancy, 2004). Nationally  

Nearly 3/4 of adolescent women aged 15-17 reported having discussed sex or sexuality with at least one parent (Abma et al, 2004).

60% of adolescents reported that a parent or guardian was aware that they were accessing family planning services at the clinic (Jones et al., 2005b).

In California 

The vast majority (79%) of teens in California indicated that their parents were aware of their sexual activities (CHIS, 2002).

Parents

 Slightly over half of parents (55%) support parental involvement laws, however they also expect that mandated involvement requirements will have at least one (98%) or more (48%) negative consequences (Eisenberg et al, 2005).

 In focus group research, parents indicated that

their priority is that their teens be safe.

  “they want their daughters to get safe, professional medical care and counseling in a timely way, …even if their daughters feel that they can’t come to them”… “you can’t force every family to communicate” (Dial Group Research, 2005)

Health Professionals

Health professionals serve an important role in encouraging young people to communicate with their families

Health professional

 A recent survey of Title X clinics demonstrated that clinics engage in a wide range of activities designed to promote parent-child communication, including:   Counseling adolescents on the importance of talking to their parents (95%); Distributing pamphlets on strategies for communication (84%);   Sponsoring social events (such as health fairs) for parents and adolescents (70%); and Promoting communication on posters and websites (54%) and as part of media campaigns (45%).

Jones, 2006

Health Professionals

  Laws that seek to balance minors’ and parents’ rights often give discretion to physicians to determine when disclosure is warranted.

With regards to reproductive healthcare, most professional medical organizations have issued policy statements expressing the importance of confidential care    American Medical Association (AMA) American College of Obstetrics and Gynecology (ACOG) Society for Adolescent Medicine (SAM).

Policymakers & Advocates

Policy makers strive to recognize the public health implications of lack of confidentiality for adolescents and the impact of such requirements on not only the teen’s health and well-being, but on society as a whole.

.

Policymakers & Advocates

 50 states allow minors to consent to STI & HIV testing.  21 states allow minors to consent to contraceptive services; over 20 states allow minors to consent to substance abuse/mental health services and related care.  Title X funded family planning clinics  Require delivery of confidential care when requested  Require that physicians encourage parental involvement Jones & Boonstra, 2005

Parental Involvement Legislation in the U.S.

 Parental involvement requirements were first passed in the mid 1970’s.

 Recently, there has been a surge in both the consideration and passage of parental involvement legislation.

 In the

first 6 months

of 2005, five states – Arkansas, Florida, Georgia, Oklahoma, and Texas previous

five years.

– altered or adapted parental involvement in minors’ abortion requirements, more than had done so in the

Parental Involvement Legislation in the U.S.

44 states have passed parental involvement legislation 22 states currently require parental consent 13 states currently require parental notification 2 states currently require the consent of both parents 1 state currently require notification of both parents Courts in 9 states have permanently or temporarily enjoined such requirements The Alan Guttmacher Institute, 2006

Parental Involvement Legislation in the U.S.

Alternatives to parental involvement requirements 34 states include a judicial bypass option 6 states allow a grandparent or other adult relative to take the place of parent consent or notification 4 states allow specified health professionals to waive parental involvement requirements if a judge is unavailable

Parental Involvement Legislation in the U.S.

Exceptions to parental involvement requirements  28 states permit exception to parental involvement requirements in cases of medical emergency  12 states permit exception to parental involvement requirements in cases of rape, incest, or assault

The history of parental involvement legislation in California

 1987 parental consent law Minors need written consent of one parent for abortion (unless they obtain court order authorizing abortion)       Legal challenge

Brought by American Academy of Pediatrics, California Medical Association, American College of Obstetricians & Gynecologists, and Planned Parenthood Claim that law violates Article I, Section 1 of California Constitution:



“All people” possess certain fundamental rights, including “privacy” Law is never enforced because of court orders Trial San Francisco Superior Court, which rules law unconstitutional in 1992 Court of Appeal affirms 1994 California Supreme Court affirms 1997

The history of parental involvement legislation in California

Proposition 73   Ballot initiative on the November 8 th , 2005 special election ballot      

Parental notification Mandatory 48 hour waiting period Judicial bypass option/medical emergency provisions Reporting requirements for physicians & judges Civil penalties against physicians Definition of abortion in California Constitution changed to include “unborn child” Defeated

52% to 48%

Parental involvement legislation in California

Proposition 85

November 7 th general election

Constitutional amendment to prohibit abortion for unemancipated minors until 48 hours after physician notifies minor’s parent or legal guardian, except in medical emergency or with parental waiver.

Parental involvement legislation in California

Proposition 85   Parent/guardian must be notified:   In person or via certified mail Physician cannot provide abortion care until 48 hours after parent received notification.

Exceptions:    Medical emergencies Waivers pre-approved by parent or guardian Judicial bypass (waiver approved by the Court) 

Minor must provide clear and convincing evidence that parental notification is not in her best interest or that she is mature enough to make the decision without parental involvement.

Parental involvement legislation in California

Proposition 85  Creates new reporting requirements  Health care providers must provide details on number of abortions performed and some minor demographic characteristics.  Minors’ name not included, physician’s name included – although not “public record”.  Authorizes monetary damages against physicians for violations.

Will this policy have its intended effect?

Will there be a decline in the frequency with which young women seek abortion care?

Will there be an increase in parental communication and involvement in reproductive health decision-making?

Will parental involvement requirements change the age dynamics of relationships?

Measuring the impact of parental involvement requirements

Challenges in Analyzing Available Data

     Measuring out-of-state travel Accurate reporting of abortion statistics Overall declines in teen pregnancy Vast majority of recent studies are from the mid 1990’s, only one recent analysis Variations in study design

The impact of parental involvement requirements

On the frequency of abortion and out-of-state travel  Massachusetts  

After implementation of a parental consent requirement, half as many minors obtained an in-state abortion.



Clinic personnel estimate that 75% of these young women had obtained parental consent, whereas 25% had obtained judicial bypass.

An increase in out-of-state travel during this same time period accounted for 95% of the decline in the abortion rate.



Over 1,800 minors traveled to 5 neighboring states to obtain out-of-state abortion care in the 20 months following the law’s implementation.



1 out of every 3 minors seeking abortion care traveled out of state for care after implementation of the state law.

Cartoof & Klerman, 1986

The impact of parental involvement requirements

On the frequency of abortion and out-of-state travel 

Missouri

 After implementation of a parental consent requirement, the in-state abortion rate declined by 20%.

 During this same time period, the odds of traveling out of state for abortion care increased by 50%.

Ellerston, 1997

On a related note: the impact of mandated parental notification for contraceptives

   Texas recently became one of 3 localities (in addition to Utah and McHenry county, Illinois) to mandate parental notification for the provision of prescription contraceptives. It has been estimated that the loss of confidentiality in family planning service provision in TX will result in an additional 8,000 pregnancies, 5,000 teen births, and 1,600 abortions to teens annually. The total projected cost of this loss of confidentiality is estimated at over $43 million (Franzini et al, 2004).

Legislation that would mandate parental notification for provision of prescription contraceptives is currently under consideration nationally

.

“The Parents Right to Know Act”

The impact of parental involvement requirements

What is the effect of these laws on the timing of adolescents’ abortions?



There is an increased risk of complications if an abortion is delayed into the 2 nd trimester.

 

Adolescents, on average, take 1 week longer to identify a pregnancy and 2 weeks longer to seek abortion care than adult women (Boonstra et al., 2006).



In Mississippi, adolescents were 10 20% more likely to delay their abortion into the 2 1995).

nd trimester after implementation of a parental consent requirement (Henshaw, Following implementation of Missouri’s parental involvement requirement, a steady but irregular increase in the percent of abortions to young women occurring after 12 weeks gestation was observed, from 17% (1980) to 26% (1992).

The impact of parental involvement requirements

What is the effect of these laws on the timing of adolescents’ abortions?

  An analysis of national data from 1974-1999 showed that states with parental involvement requirements have a higher share of post-first trimester abortions (Bitler & Zavodny, 2001).

A 2006 study in the

New England Journal of Medicine

demonstrated that teens in Texas who were 17.5 or older when the state’s parental notification law took effect were significantly more likely to have a 2 nd trimester abortion than younger teens (Joyce et al., 2006).

The impact of parental involvement requirements

  Is the judicial bypass option a viable choice?

A study in Pennsylvania found that 8 out of 60 judicial court districts provided complete information to young women inquiring about the judicial bypass option (Silverstein, 1999). A study of Alabama’s juvenile court system found the information received was inconsistent and oftentimes reflected the court employee’s personal opinion on abortion (Silverstein & Speitel, 2002).

“Call information…just ask for an abortion clinic. If they say you need parental approval, then you’re going to have to have parental approval, because I don’t think a judge can order an abortion.” “You’ll have to go to Jefferson County to get that done. Our judge doesn’t do it; he doesn’t believe in it.” “Honey, I have no idea, I just have no idea. I feel like I don’t believe a judge or even a lawyer actually would do that….It would be best for you to talk to your parents.”

Will this policy have its intended effect?

Will there be a decline in the frequency with which young women seek abortion care?

 Reduction in adolescent abortion rate.  Increase in frequency of out-of-state travel for abortion.

 Increase in complications to accessing care:  Delay  Judicial bypass inconsistencies.

Parental involvement in minors abortion decisions

Will there be an increase in parental communication and involvement in reproductive health decision-making?

Parental involvement in minors abortion decisions

  How involved are parents in the absence of government mandates ?

Most parents (61%) are aware of their daughters’ decision to seek abortion care.

  Among younger adolescents, parental involvement is even higher 

Over 90% of 14 year olds & 75% of 15 year olds report the involvement of at least one parent.

When one parent is involved, young women involve their mothers (59%) more frequently than their fathers (26%).

Over 80% of adolescents report that they involved at least one adult (such as a parent, nurse, counselor, or clergy member) in their decision.

Henshaw & Kost, 1992

The impact of parental involvement requirements

On parental involvement in abortion decision-making  A comparison of two states, with and without mandated notification requirements, demonstrated that parental involvement rates were similar regardless of the state law (Resnick & Blum, 1987).

Parental notification requirement Frequency of parental involvement in abortion decision Minnesota Yes, one parent

65%

Wisconsin None

62%

Parental involvement in minors’ abortion decisions

Why some teens do not involve their parents Over 30% of young women who chose not to involve their parents in their abortion decision cited: • Fear of physical harm, • Being kicked out of the house, or • Other abuse as part of their decision not to involve their parents. A study of the judicial bypass procedure also revealed that many other women choose not to involve their parents because of an existing difficult family situation, including drug dependency, loss of jobs, health problems, and marital strain. Henshaw, 1992 & Donovan, 1983.

Will this policy have its intended effect?

Increase in parental communication and involvement in reproductive health decision-making?

 Parental communication is high  Mandated involvement requirements do not significantly increase the rate of parental involvement

The impact of parental involvement requirements

On age differences between adolescent women and their sexual partners TX- 2002 TX- 2001 TX- 2000 TX- 1999 0% 20% 40% 60% 80% 100% Source: Special request of Texas Department of Health Services, birth rate data 1999-2002 <=17 18- 19 20- 24 >=25

After implementation of a parental notification requirement in 2000, there was no significant change in the age distribution of fathers in Texas .

Will this policy have its intended effect?

Increased identification of abusive or coercive relationships?  Not directly studied, although evidence suggests no effect.

 Health care providers role as a mandated reporter ensures that they report coercive, abusive, or inappropriate relationships to proper authorities.

Existing Evidence Points to:

  

Patchwork of Laws:

Existing parental notification and consent laws vary across the country, resulting in a variety of outcomes that have deep repercussions for adolescents’ lives. Even without mandates, California’s teen pregnancy, births, and abortions have significantly been reduced.

Many of the laws have negative impacts-

-delays in seeking abortion care, judicial bypass, travel out of state.

Medical care providers have an important role to play

option to speak with their families.

in encouraging parent and adolescent communication, without creating barriers for adolescents when they do not have the

References

Abma JC, Martinez GM, Mosher WD, Dawson BS. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2002.

Vital Health Statistics; Vol 23 no 24.

National Center for Health Statistics, 2004. Bitler M, Zavodny M. The effect of abortion restrictions on the timing of abortions.

J Health Econ

. 2001. 20:1011-1032.

Blum R. Resnick M, Stark T. The Impact of a Parental Notification Law on Adolescent Abortion Decision Making.

Am J Public Health

. 1987; 77:619-620.

Boonstra H et al.

Abortion in Women’s Lives

. New York: Guttmacher Institute, 2006. Cartoof V, Klerman L. Parental Consent for Abortion: Impact of the Massachusetts Law. Am J Public Health 1986; 76:397 400. Dial Group Research, Focus Group on Parents’ Beliefs Regarding California’s Prop 73 Proposition. Unpublished Report, Sacramento, Ca. 2005 Donovan, P. Judging teenagers: how minors fare when they seek court-authorized abortions.

Family Planning Perspectives

1983; 15(6): 259. Ehrlich S. Grounded in the reality of their lives: Listening to teens who make the abortion decision without involving their parents.

Berkeley Womens Law Journal

What Do Parents Say? 2003. 18: 61-180. Eisenberg M, Swain C, Bearinger L, Sieving R, Resnick M. Parental Notification Laws for Minors’ Access to Contraception:

Arch Pediartr Adolesc Med

. 2005; 159:120-125. Ellerston C. Mandatory Parental Involvement in Minors’ Abortions: Effects of Laws in Minnesota, Missouri, and Indiana.

Am J Public Health.

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JAMA.

1997; 278:1029-1034. Franzini L, Marks E, Cromwell P, Risser J, McGill L, Markham C, Selwyn B, Shapiro C. Projected Economic Consequences Due to Health Consequences of Teenagers’ Loss of Confidentiality in Obtaining Reproductive Health Care Services in Texas.

Arch Pediatr Adolesc Med

. 2004; 158: 1140-1146. Henshaw S, Finer L. Abortion Incidence and Services in the United States in 2000.

Perspectives on Sexual and Reproductive Health

2003: 35(1): 6-15. Henshaw S, Kost K. Parental Involvement in a Minors’ Abortion Decision.

Family Planning Perspectives

. 1992; 24(5). Henshaw S. The Impact of Requirements for Parental Consent on Minors’ Abortions in Mississippi.

Family Planning Perspectives

, 27: 120-122, 1995.

Jones, R. Do US family planning clinics encourage parent-child communication. Findings from an exploratory study. Perspectives on Sexual and Reproductive Health 2006; 38(3): 155-161.

References

, cont.

Jones R, Boonstra H. Confidential reproductive health care for adolescents.

Curr Opin Obstet Gynecol

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Jones R, Darroch J, Henshaw S. Contraceptive Use Among U.S. Women Having Abortions in 2000-2001.

Perspectives on Sexual and Reproductive Health

2002: 34(6): 294-303. Jones R, Purcell A, Singh S, Finer L. Adolescents’ reports of parental knowledge of adolescents’ use of sexual health services and their reactions to mandated notification for prescription contraception. 2005; 293: 340-348.

Jones R, Singh S, Purcell A. Parent-child relations among minor females attending U.S. family planning clinics.

Perspectives on Sexual and Reproductive Health

2005; 37(4): 192-201. Joyce T, Kaestner N, Colman S. Changes in abortions and births and the Texas parental notification law.

NEJM

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Reddy D, Fleming R, Swain C. Effect of Mandatory Parental Notification on Adolescent Girls’ Use of Sexual Health Silverstein H, Speitel L. “Honey, I have no idea”: Court readiness to handle petitions to waive parental consent for abortion. Sutton P, Mathews TJ. Trends in Characteristics of Births by State: United States, 1990, 1995, and 2000-2002.

National Vital Statistics Reports

Available at: : Vol 52 no 19. Hyattsville, Maryland: National Center for Health Statistics, 2004. The Alan Guttmacher Institute. U.S. Teen Pregnancy Statistics: Overall trends, Trends by Race and Ethnicity And State-by State Information. New York, NY: The Alan Guttmacher Institute; 2004. The Alan Guttmacher Institute. Parental Involvement in Minors’ Abortions, State Policies in Brief, August 15, 2005 [online]. http://www.agi-usa.org

. Accessed August 20, 2005. The National Campaign to Prevent Teen Pregnancy. Parents and Teen Pregnancy: What Surveys Show [online] 2004. Available at http://www.teenpregnancy.org

. Accessed September 7, 2005. UCLA Center for Health Policy Research. California Health Interview Survey [online] 2001. Available at: http://www.chis.ucla.edu/ . Accessed August 7, 2005.

Contact information & additional resources



Claire Brindis

 [email protected]

 Copies of the

Adolescents and Parental Notification for Abortion: What can California Learn from the Experience of Other States?

brief and this PowerPoint presentation are available at: http://crhrp.ucsf.edu

 Special thanks to:   Maggie Crosby, JD Lauren Ralph, MPH